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SA N JOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> Stephanie Charissa 916-343-3857 <br /> FACILITY NAME: FACILITY PHONE# <br /> Triangle Plaza Tracy <br /> FACILITY ADDRESS: CROSS STREET: <br /> 3788 Tracy Blvd., Tracy, CA 95304 1-205 <br /> OWNER/OPERATOR: PHONE: <br /> 3788 Tracy, LLC 408-638-1339 <br /> CONTRACTOR NAME: PHONE: <br /> Walton Engineering, Inc. 916-343-3857 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> PO Box 1025, West Sacramento, CA 95691 617238 /A,B,Haz <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> VYES NO SAMTWC10020101 <br /> FIRE DISTRICT: PERMIT# <br /> South San Joaquin County Fire Authority F24-0074 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 24K 87 GAS TBD <br /> 2 6K E-85 TBD <br /> 3 15K B-20 TBD <br /> 4 15K 91 GAS TBD <br /> ❑APPROVED PPPROVED WITH CONDITIONS ❑DISAPPROVED <br /> �j (see attachments) <br /> PLAN REVIEWER'S NAME I�gc, DATE 10 130 1!J <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.,I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."�f..s�� <br /> Applicant's Signature sr� ! <br /> f,Gtf"GS� <br /> Title Operations Coordinator Date 08/09/24 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Stephanie Charissa Date ns/n9/24 <br /> Mailing Address PO Box 1025, West Sacramento, CA 95691 <br /> Signature SbALa,du,P,-duw&-., Daytime Phone 916-343-3857 <br /> 3of8 <br />